Depression Group Registration 
When: January 7, 14, 21, 28, February 4, & 11

Time: 6PM-7PM

Where: 8050 Rowan Road, Suite 301, Cranberry Twp, PA 16066

Questions? email: amandaw.dunlap@gmail.com
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First & last name of person completing this registration form: *
Please list the primary phone number: *
Please list the primary email address: *
First & last name of person attending group: *
Date of birth of person attending group: *
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Please list the following:
1. Insurance group (i.e UPMC, Highmark, Aetna)
2. Member ID number

**Please note that we can only accept commercial UPMC, Highmark/BCBS, Aetna and Cigna plans; the out of pocket fee is $40 per session
 *
I understand that my insurance benefits will be checked before the group starts. *
Required
I understand that if my insurance does not cover group therapy, the clinician will reach out to me via email and give me the option of the self pay fee of $40. *
Required
I understand that I will be asked to place a credit card on file at the first group therapy session for my child to cover the benefits of my insurance (i.e copay, deductible, coinsurance). *
Required
Being that this is a group session, I understand that there is no financial penalty if my child does not show for a session, however if 2 sessions are missed in a row without any prior notice to the clinician, my child will be terminated from the remainder of the group. 

**If you know you cannot make it to a session, I would greatly appreciate a heads up via email just so I can set my expectation for the evening
 *
Required
I understand that if a session needs to be cancelled by the clinician for any reason I will be notified via email. *
Required
I understand that I will receive a follow up email confirming my registration to the group sessions within 48-72 hours of submitting this form.  *
Required
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